Utilization Management RN

UVA Health

2d•Onsite

About The Position

Under general direction, the Utilization Management RN serves as a leader resource in the Utilization Management process. They collaborate with physicians and other members of the healthcare team to promote and adhere to regulatory compliance. The UM RN conducts initial concurrent and retrospective medical necessity reviews. All Utilization Management activities are performed in accordance with the mission, vision, and values of UVA Medical Center. This role involves analyzing and evaluating complex medical documentation, demonstrating competence in the interpretation of clinical data and the application of UM tools. The UM RN collaborates with physicians and the care team, utilizing judgment and critical thinking to determine which cases to refer for second-level review to external physician consultants and internal UVA UR MDs. They are responsible for providing complete, accurate, and timely clinical data to insurance companies, and using judgment and critical thinking to determine if denied cases will be appealed, utilizing medical, contract, and payor rules. The UM RN conducts appeals with external entities and consultants, manages appealed cases including external review and resolution for billing, and actively supports the financial mission of the department. They practice according to department standards, assume responsibility for their own professional development, and contribute to the professional development of others, demonstrating leadership in the UM role. In addition to the above job responsibilities, other duties may be assigned.

Requirements

Bachelor of Science in Nursing from accredited nursing program.
2 years acute care hospital experience.
Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.

Responsibilities

Conducts initial concurrent and retrospective medical necessity reviews.
Analyzes and evaluates complex medical documentation.
Demonstrates competence in interpretation of clinical data, and the application of UM tools.
Collaborates with physicians and care team: Attending, resident, mid-level practitioners.
Utilizes judgment and critical thinking in determining what cases to refer for second level review to external physician consultants and internal UVA UR MD’s.
Provides complete, accurate, and timely clinical data to Insurance companies.
Utilizes judgment and critical thinking to determine if denied cases will be appealed utilizing medical, contract and payor rules.
Conducts appeals with external entities and Consultants.
Manages appealed cases including external review and resolution for Billing.
Actively supports the financial mission of the department.
Practices according to department standards.
Assumes responsibility for professional development of self and contributes to and assists with the professional development of others.
Demonstrates leadership in the UM role.